Nursing Processes for Emesis Management

Nursing Processes for eliminate ManagementNausea and retch atomic number 18 common complications of multiple conditions, procedures, therapies, and events such as trans act ailment, pregnancy, anesthesia ( world(a), regional, or local) or radio/chem an early(a)(prenominal)apy. Symptoms foot be debilitating for m either patient ofs, and in the case of post-operative malady and vomiting (PONV) physical damage may result, such as rupture of sutures, stitches, and esophageal tissue, and metabolic problems, such as electrolyte imbalances and dehydration (Golembiewski et al, 2005 Gan 2006). In abominable cases of PONV, although rargon, goal of gastric contents may occur, resulting in pulmonary sequelae, such as pneumonia or pneumothorax (Scuderi and Conlay 2003 Bremner and Kumar 1993). Thus good word of PONV, possibly through multimodal antiemetic dose medicine prophylaxis, is an distinguished ar of research (Skledar et al. 2007).This undertake will con nerver two comm only if apply, headspring-recognized antiemetic preachings namely cyclizine and prochlorperazine. Both re extradite very old medicate therapies, with cyclizine having been launched as an antiemetic in 1953, and prochlorperazine as an antipsychotic in 1957 (Broccatelli, 2010), its use as an effective antiemetic emerging soon accordinglyceforth (Finn et al, 2005). These doses atomic number 18 normally apply on or so wards in my execute setting and in that locationfore it is vital for nursing staff to understand their several(prenominal) pharmacodynamic (PD) and pharmacokinetic (PK) profiles. Prior to prescribing it is besides important that the concord cause relevant knowledge regarding how these drugs work, how their PD and PK properties are deepened by disease processes such as kidney/liver loser and whether there are any relevant contraindications or precautions. Additionally, the authorization for drug-drug fundamental interactions and the dit appr opriate for the patients age and weight should be discovered if beneficial patient orientated outcomes are to be achieved. These issues will be comprehensively discussed at smell this essay.Pharmacology of emesisThere are a plethora of drugs on the market to treat emesis, however, deciding upon an appropriate and effective word for patients requires the pillowcase of the inherent nausea and vomiting to be ascertained. This is because the symptoms seat manifest as a result of a number of underlie pharmacologic processes, as will now be described. cat is a complex reflex action controlled by the vomiting centre (VC) in the medulla region of the brain, an important part of which is the chemotrigger z maven (CTZ) stimulation of this in turn leads to VC stimulation which ultimately leads to vomiting (Goodman Gilman, 1996). Neurotransmitter mediated stimulation of the VC tramp arise from two peripheral and central impulses (Shanbhag, 2008). Thus gastro intestinal irritation, mo tion disease and vestibular neuritis all manifest in nausea and vomiting as a result of neurotransmitter release. The iii main neurotransmitters involved in the control of vomiting are acetylcho class (ACh via muscarinic- receptors), dopamine (via dopaminergic receptors), histamine (via H-1 receptors), and serotonin (via 5-HT3 receptors) (Shanbhag, 2008). Inhibition or antagonism of these receptors achieves emetic control.The VC has neurons which are rich in muscarinic cholinergic and histamine containing synapses and is right away stimulated by the vestibular input (e.g. through motion sickness), whilst dopamine and serotonin release are involved in the visceral stimuli alley (e.g. through chemotherapy treatment) and a deal in the CTZ stimulation pathway as shown in Figure 1. Thus drug classifications of anti-emetics arise on the basis of which of the three pathways that they butt (Flake et al., 2004). Selective serotonin receptor antagonists and antidopaminergics home run the visceral stimuli and the CTZ, whilst the antihistamines and anticholinergics target the vestibular input pathway (Hornby , 2001 Flake et al., 2004).Etiology of Nausea and VomitingCyclizines anti-emetic make are not fully understood but it is sentiment that it works by blocking the transmission of information from the labyrinthine machine in the inner ear (i.e. the vestibular pathway) to the VC (Goodman and Gillman, 1996).Cyclizine may likewise target the CTZ and it thought process to exhibit some ACh muscarinic receptor blockade which probably ease up to the antiemetic authorization thus operating at several pathophysiological levels. However, a side effect of ACh blockade is sedation in some individuals on with the potential for certain deliriant and hallucinogenic effect, probably responsible for cyclizines abuse potential (Bailey and Davies, 2008). Cyclizine produces its antiemetic effect within 2 hours and it lasts approximately four hours (emc, n.d.).The conduct mechanism of prochlorperazines antiemetic action is similarly unclear, but the drug is thought to inhibit apomorphine induced vomiting by blocking dopamine D2 receptors centrally in the CTZ and possibly peripherally through dopaminergic receptors in the intestine (Perwitasari, 2011). However, it overly has some potential to block anticholinergic and alpha-adrenergic receptors, and whence toilet in any case result in sedation along with muscle relaxation, and orthostatic hypotension (Kelly, 2000). next intramuscular administration prochlorperazine has an onset of action within ten to twenty dollar bill proceeding and a duration of action of three to four hours (globalrph, n.d.).Indications and venereal infection formCyclizine is indicated for the control of postoperative and drug-induced vomiting and in motion sickness (BNF, 2012 emc, n.d.). It is given by mouth at a pane of icing of 50mg checks up to three propagation a day or arouseerally as a 50mg in 1ml solution intra muscular (im) or intravenous (iv) stroke again at a frequency of up to 3 multiplication a day (Reynolds, 1993). The recommended dose in children aged 6-12 years is impose 25 mg up to 3 generation daily. For motion sickness, it is recommended that tablets be interpreted 1-2 hours before departure. Cyclizine stern overly be given for silliness and, morning sickness in pregnancy, and to combatopioid nausea. It is also appointive for radiotherapy sickness (medsafe, n.d.) and PONV (Cholwill et al., 1999), indeed it is given iv before the induction of general anaesthesia at half the recommended dose, to increase the lower oesophageal sphincter notation thus reducing the hazard of regurgitation and aspiration of gastric contents (medsafe, n.d.).Although prochlorperazine is classified as an antipsychotic, its principal use nowa geezerhood is in the treatment of grim nausea and vomiting of various causes including, PONV, vertigo and motion sickness (BNF, 2012). It has several batt ery-acid forms tablet (5mg one or two tablets 3-4 times daily), syrup (5mg in 5ml 5-10 ml 3-4 times daily), suppositories (25mg double daily), dissolvable tablet (buccal tablet 3mg one or two tablets doubly a day in adults and children aged 12 years and over), im barb (12.5mg in 1ml 5-10mg ingeminate every 3-4 hours with a maximum daily dose of 40mg) and iv injection (2.5 -10 mg by slow IV injection or plectronwith a maximum daily dose of 40mg). The oral (and buccal) route is the only method of administration recommended for children, and it is not recommended in children younger than12 years (BNF, 2012). The incompatible dosage form of prochlorperazine provides the foster with flexibility for voice the ancient and children may prefer the syrup or buccal tablet, or in dysphagia suppositories or intra-muscular injections could be much appropriate.Cyclizine and prochlorperazine are some(prenominal) considered kickoff line treatments for nausea secondary to vertigo and motio n sickness (Quigley, 2001) and are get-go line treatments in many hospitals in PONV (NHS, Salisbury NHS Plymouth). A limited review by Matchar, et al. (2003) has suggested that oral prochloperazine may also be utilize as an adjunct in the treatment of nausea associated with hemicrania (Matchar et al, n.d.). No disarrange controlled trial has been found which formally compares talent of cyclizine and prochlorperazine, however, two studies comparing cyclizine with perphenazine in ameliorating drug-induced emesis, have shown the former to have similar antiemetic efficacy to this related phenothiazine drug (Dundee et al., 1975 Chestnutt and Dundee, 1986). These studies are feature in a Cochrane report (Stevenson, 2006) which investigates drugs for preventing PONV and highlights eight drugs which reduce PONV by a quasi(prenominal) amount in this patient group, cyclizine being one. The report concluded, therefore, that the most important question to answer when treating emesis i s What are the types and risks of side set up experient by patients exposed to these antiemetics? Thus safe and effective prescribing requires the nurse to diagnose patient variants or comorbidities relevant to the drugs side effect, for example heart failure patients should not be prescribed cyclizine and individuals susceptible to visual disturbances should suspend prochlorperazine as per the drugs contraindications. It is noteworthy that both drugs may be prescribed in the later on stages of pregnancy if considered appropriate by a doctor (Schaefer, 2007 CKS, n.d.).1The excerption of antiemetic would depend upon the precise cause of the nausea in pairing with the proper(postnominal) receptor affected. However, since several take issueent neurotransmitters stimulate the CTZ, combining drugs with distinguishable mechanisms of action green goddess often be more effective than change magnitude the dose of one individual drug (King and Brucker 2011). Indeed, combinations of antiemetics are often use in palliative care (NHS Scotland, n.d.). Notably, vomiting of unclear or meld descent may respond to a phenothiazine such as prochlorperazine because, in addition to acting on dopamine and serotonin receptors in the CTZ, it also acts at the VC and vestibular area.Cyclizine and prochlorperazine are both commonly apply anti-emetics in palliative care where nausea and vomiting are present in up to 70% of patients with advanced roll in the haycer (NHS Scotland, n.d.). Treating this patient state requires grumpy vigilance, since there may be a number of underlying reasons for and comorbidities bring to the nausea and vomiting, and antiemetics may be inappropriate. Consideration for causes of the symptoms might overwhelm intestinal obstruction or constipation, anxiety, raised intracranial pressure (ICP), oesophageal candida, severe distract or hypercalcaemia all of which might warrant interventions other then antiemetics. Conversely, should the naus ea and vomiting be identified as drug induced, then anti-emetics such as cyclyzine or prochlorperazine might be appropriate. embossed intracranial pressure stimulates vomiting centre via pressure receptors and can be knotted in patients with known or suspected brain metastases. Notable, cyclizine can be given to such patients, especially where corticosteroids are contraindicated (NHS Scotland, n.d.).PharmacokineticsCyclizine, like most antihistamines, is well absorbed from the GI tract. After oral doing the effects develop within 30 minutes, are maximal within 1-2 hours and lasts for 4-6 hours. A single oral dose of 50 mg cyclizine in healthy adult volunteers resulted in a peak plasma concentration of approximately 70 ng/mL, occurring at about two hours after drug administration. The plasma elimination half life is approximately 20 hours.2Cyclizine is extensively metabolised in the liver via N-demethylation to the unruffled metabolite norcyclizine (Figure 4), which is extensive ly distributed throughout the tissues and has plasma half-life of approximately 20 hours. This metabolite has forgivable antihistaminic activity compared to parent drug. A single 50 mg dose of cyclizine when given to an adult male volunteer, results in less than 1% of the make sense dose administered being excreted as parent drug in the urine over a 24 h period. Thus urinary excrement of metabolite rather than parent drug is the major route of elimination forcyclizine. The metabolic process is thought to be mediated through CYP 2D6 and therefore exhibit inter-subject divergence dependent upon the CYP 2D6 genotype as demonstrated by Vella-Brincat et al. (2012) in their subject of the PK of cyclizine (Appendix 1) and its major metabolite (Appendix 2) in palliative care patients receiving sub-cutaneous cyclizine. Results indicated that the metabolic ratio of parent drug to metabolite differed significantly according to CYP2D6 genetics.3Prochlorperazine is reasonably well absorbed from the GI tract and highly protein bound. It undergoes extensive metabolism both in the gastric mucosa and on first pass through the liver via the cytochrome P450 enzyme constitution (CYP 2D6 and CYP 3A4)4to inactive metabolites, which are subsequently excreted in the urine. Parent drug has a plasma half-life of between 4 and 8 hours, the precise half-life differing according to the mode of administration. An im injection produces its antiemetic effect in 5-10 minutes and it lasts for 3-4 hours. Onset of effects are related to the mode of administration hence the pharmacokinetic profile, thus an oral dose would have a slightly slow-moving onset of action but would last longer compared with an im injection.5According to Finn et al (2005), although the drug has been accepted as a useful anti-emetic for over half a century, its therapeutic success has been limited by its low and variable absorption and high first-pass metabolism. However, the development of a new buccal grooming has improved the PK, since studies demonstrate that buccal administration of prochlorperazine produces plasma concentrations more than twice as high as an oral tablet, with less than half the division (Finn et al., 2005)6(Figure 5). When placed in the buccal cavity between the upper lip and the gum the formulation forms a gel from which the prochlorperazine is released and absorbed. The plasma levels achieved at steady-state on a dosage regimen of one 3mg buccal tablet twice daily are similar to those observed with the standard oral dosage of one 5 mg tablet taken three times daily. The elimination half-life of prochlorperazine in this formulation is 9 hours. The safety and efficacy of this relatively new formulation has also been demonstrated by cleave7(1998) in a randomised, double-blind, double-dummy trial in patients with vestibular disorders.Side effectsBy virtue of their pharmacology, cyclizine and prochlorperazine are both central depressants and can cause injury of perfo rmance (Benson, 2001). Consequently, the pharmaceutical data sheets for both drugs have warnings regarding their potential to interfere with the ability to drive or operate machinery safely collect to their ability to cause drowsiness (BNF, 2012). Despite the fact that cyclizine is one of the honest-to-goodness antihistamines it is considered less potent in this regard compared to others in its class (Broccatelli, 2010), however, there is considerable variability in response to this side effect which can range from slight drowsiness to deep sleep. For this reason in practice, when one drug is not effective or poorly tolerated then it is excusable to give another drug or combination of drugs (Benson, 2001). This unwanted side-effect is also a feature of prochlorperazine especially in the elderly, and often diminishes with continued treatment of both drugs (emc, n.d.).Cyclizines other more common side-effects include headache and psychomotor impairment asset antimuscarinic effects , such as urinary retention, dry mouth, fuzzy vision, and gastrointestinal disturbances (BNF, 2012). Less common side effects are palpitations and arrhythmias, also dizziness, hypotension, muscular weakness and poor coordination (Goodman and Gilman, 1975).Prochlorperazine commonly causes CNS related side effect such as acute dystonia or dyskinesia, however these unravel to be transitory ( unremarkably occur within the first 4days of treatment) and are more common in children and young adults. Dopamine antagonists like prochlorperazine can also cause extrapyramidal effects, QT prolongation and even severe hypotension, especially in the elderly (emc, n.d.). Muscle spasms and restlessness are other inform side effects.InteractionsCyclizine exhibits pharmacological interactions with other drugs due to antagonism of its action (donepezil, galantamine, rivastigmine) or enhanced anticholinergic actions (tacrine, trimethobenzamine, triprolidine, trospium). Pharmacokinetic interactions ma y arise since cyclizine is an inhibitor of the liverwort CYP 2C9 isozyme system, which is involved in an NADPH-dependent electron transport pathway. This isozyme oxidizes a variety of structurally unrelated compounds, including steroids, buttery acids, and xenobiotics and contributes to the wide pharmacokinetics variability of the metabolism of drugs such as S-warfarin, diclofenac, phenytoin, tolbutamide and losartan. Pethidine and propanidid are also listed as having a potential to interact with cyclizine. Cyclizine also acts as an inhibitor of estrogen sulfotransferase, the enzyme responsible for estradiol metabolism.Prochloperazine has a plethora of interactions, both pharmacological and pharmacokinetic. The pharmacokinetic interactions are by and large due to competitive metabolic interactions at the hepatic CYP 3A4 and CYP 2D6 enzymes. The CYP 3A4 isozymes are responsible for a variety of oxidation reactions e.g. caffeine 8-oxidation, omeprazole sulphoxidation, midazolam 1-hy droxylation and midazolam 4- hydroxylation, plus metabolism of structurally unrelated compounds, including steroids, buttery acids, and many other xenobiotics. Whilst the CYP 2D6 isozymes are responsible for the metabolism of many drugs and environmental chemicals, via oxidative transformation along with metabolism of drugs such as antiarrhythmics, adrenoceptor antagonists, and tricyclic antidepressants.9Consequently, the data sheet for prochlorperazine lists many drugs with interaction potential including ad nephriticine, amphetamine, carbamazepine, clonidine, desferrioxamine, guanethidine, levodopa, lithium, phenobarbital and propranolol.Managing drug TherapyWhen managing the care of a patient, nursing staff must initially exhaustively assess the patient, then identify significant interactions between core drug knowledge (PD, PK, ADRs, interactions, contraindications) and the patients core variables (health status, age and gender, life-style and diet, environments, culture). T hereafter the nurse can plan and implement suitable interventions, which will maximise therapeutic effects whilst minimising adverse effects (Aschenbrenner and Venable, 2008). In order to achieve such objectives the nurse should ensure administration of the appropriate medication is given through a suitable route on a regular basis or as necessitate, with ongoing patient evaluation and observe.Cyclizine and prochlorperazine are both considered first line treatments for nausea secondary to vertigo and motion sickness (Quigley, 2001) and are first line treatments in many hospitals in PONV (NHS, Salisbury NHS Plymouth). A review by Matchar, et al. (2003) has suggested that oral prochloperazine may also be used as an adjunct in the treatment of nausea associated with migraine (Matchar et al, n.d.). No randomized controlled trial has been found which formally compares efficacy of cyclizine and prochlorperazine, however, two studies comparing cyclizine with perphenazine in ameliorating drug-induced emesis, have shown the former to have comparable antiemetic efficacy to this related phenothiazine drug (Dundee et al., 1975 Chestnutt and Dundee, 1986). These studies are featured in a Cochrane report (Stevenson, 2006) which investigates drugs for preventing PONV and highlights eight drugs which reduce PONV by a similar amount in this patient group, cyclizine being one. The report concluded, therefore, that the most important question to answer when treating emesis is What are the types and risks of side effects experienced by patients exposed to these antiemetics? Thus safe and effective prescribing requires the nurse to identify patient variables or comorbidities relevant to the drugs side effects, for example heart failure patients should not be prescribed cyclizine and individuals susceptible to visual disturbances should debar prochlorperazine as per the drugs contraindications. It is noteworthy that both drugs may be prescribed in the later stages of pregnancy i f considered appropriate by a doctor (Schaefer, 2007 CKS, n.d.).10The excerpt of antiemetic would depend upon the precise cause of the nausea in conjunction with the specific receptor affected. However, since several different neurotransmitters stimulate the CTZ, combining drugs with different mechanisms of action can often be more effective than increasing the dose of one individual drug (King and Brucker 2011). Indeed, combinations of antiemetics are often used in palliative care (NHS Scotland, n.d.). Notably, vomiting of unclear or mixed origin may respond to a phenothiazine such as prochlorperazine because, in addition to acting on dopamine and serotonin receptors in the CTZ, it also acts at the VC and vestibular area.Cyclizine and prochlorperazine are both commonly used anti-emetics in palliative care where nausea and vomiting are present in up to 70% of patients with advanced cancer (NHS Scotland, n.d.). Treating this patient macrocosm requires particular vigilance, since th ere may be a number of underlying reasons for and comorbidities contributing to the nausea and vomiting, and antiemetics may be inappropriate. Consideration for causes of the symptoms might include intestinal obstruction or constipation, anxiety, raised intracranial pressure (ICP), oesophageal candida, severe pain or hypercalcaemia all of which might warrant interventions other then antiemetics. Conversely, should the nausea and vomiting be identified as drug induced, then anti-emetics such as cyclyzine or prochlorperazine might be appropriate. Raised intracranial pressure stimulates vomiting centre via pressure receptors and can be problematic in patients with known or suspected brain metastases. Notable, cyclizine can be given to such patients, especially where corticosteroids are contraindicated (NHS Scotland, n.d.).Administration Precautions receivable to its centrally acting effects, patients taking cyclizine should avoid alcohol and other depressants e.g. hypnotics or tranquil lisers. Food may reduce irritation to cyclizine and since there is no interaction with food, this drug can be taken without regard to meals. The datasheet indicates it should be used with caution in hepatic disease, whilst in renal impairment there is a need for dose reduction (BNF, 2012). Cyclizine should also be used with caution in patients with severe heart failure. Other anticholinergic effects include visual disturbances, and sedation, which can make them dangerous for the elderly population or younger patients. Further, cardiovascular side effects e.g. hypotension, tachycardia, and palpitations have been reported, plus minor GI effect e.g. dry mouth and constipation. Cyclizine has a known abuse potential (Ruben et al. 2006). In opiate dependents receiving long methadone cyclizine is often taken in large doses intravenously to provide a more tearing high. Thereafter the addict experiences depressive mood changes and a craving for cyclizine. Many individuals receiving long-t erm prescriptions of oral methadone have been identified as being customary abusers of cyclizine.11Consequently, there is considerable reticence by pharmacists in prescribing the drug, and alternative treatments are generally sought. Obviously in the hospital setting there is comminuted opportunity for such abuse, and the efficacy and cost-effectiveness of the drug would therefore take anteriority over its abuse potential (Barber, 1995 Philips and Thompson, 1997).Although prochlorperazine being an antipsychotic phenothiazine drug can be employed in psychiatry, in lower doses it is usually prescribed for its anti-emetic properties. Patients taking the drug should take with a full glass of water, avoid excessive quantities of coffee or tea (containing caffeine) and also avoid alcohol. Prochlorperazine should be used with caution in patients with renal and hepatic impairment and cardiovascular disease also in Parkinsons disease, epilepsy and in patients with a archives of glaucoma. While the drug does not deliver the euphoria that is associated with many commonly abused drugs, it still has some abuse potential since it can alter mood and perception, but not to the extent of cyclizine. Moreover, dependence and tolerance can develop, which can drive the individual to continue to seek more of the drug12and result in overdose, characterised by symptoms of central nervous system falling off to the point of somnolence or coma. Agitation and restlessness may also occur in overdose. Other possible manifestations include convulsions, EKG changes and cardiac arrhythmias, fever and autonomic reactions such as hypotension, dry mouth and ileus.Managing medicine TherapyNausea and Vertigo In emetic patients, antiemetics should only be prescribed when the underlying cause is known, indeed antiemetic administration may be harmful when the cause can be treated, e.g. in diabetic diabetic acidosis or digoxin/antiepileptic overdose. In addition to motion sickness cyclizine can be given to patients with nausea caused by mechanical catgut obstruction and raised intracranial pressure.13Once a decision has been make that antiemetic drug treatment is appropriate, the drug and the dosage form should be elect according to the aetiology of vomiting along with core drug knowledge and patient variables. Thus prochloperazine is useful for episodes of more severe nausea and vomiting e.g. associated with diffuse neoplastic disease, radiation sickness, and the emesis caused by drugs such as opioids, general anaesthetics, and cytotoxics. Indeed, prophylactic use may be required if severe nausea is anticipated such as following chemotherapy treatment. (Aschenbrenner and Venable, 2008). Prochorperazine may be a suitable choice because of its dosage forms, thus rectal suppositories can be useful in patients with persistent vomiting or with severe nausea and the buccal tablet dosage form is also useful in such instances. However, during use of phenothiazines it is importan t to monitor severe dystonic reactions, especially in children. It is recommended as a second-line treatment for vomiting in pregnancy after promethazine.14Whereas the efficacy of cyclizine in treating nausea and vomiting has already been unequivocally proven, it is only available in tablet and injectable form. Nevertheless, cyclizine may be the choice of drug over prochlorperazine in children since in this patient population the latter can only be administered orally (BNF, 2012), and therefore requires patient compliance for success.There is no evidence that either of the two drugs is superior to the other in terms of efficacy also disdain cyclizines longer plasma half-life compared with prochlorperazine, the duration of action is similar at around 4 hours. The adverse event profiles do however differ slightly, because of the differing underlying pharmacology of these two drugs. This is an important consideration in the choice of drug, alongside special precautions which, as descr ibed earlier, must be considered in conjunction with patients co-morbidities. It is also noteworthy that educating patients and their families regarding the drug of choice is important for example warning patients against consuming alcohol with both prochlorperazine and cyclizine and warning patients against driving or operating machinery if susceptible to drowsiness with either drug.In summary, both cyclizine and prochloperazine have similar safety, tolerability and toxicity profiles despite their differing modes of action on a cellular level. Tolerability in terms of drowsiness is a potential problem for both drugs, but is generally dependent upon the individual patients susceptibility, warranting a trial and fracture type approach when determining which is the optimal drug of choice. Also, due to the drugs both being substrates of CYP 2D6 their phamacokinetic profiles may exhibit inter-subject variability by virtue of the different phenotypes of this enzyme which exist in the po pulation. This differing pharmacokinetic profile would logically translate into a alter response in terms of therapeutic effects. Likewise, their potential to interact with other drugs is inextricably linked with their metabolism, namely metabolic competition at the cytochrome P450 enzyme receptor sites. Thus both drugs have the potential to interact with a wide range of other medications. Moreover, since both drugs are extensively metabolised in the liver, with reasoning by elimination of metabolites in the urine, there is a need for caution in renal and hepatic disease. Cyclizine and prochlorperazine appear to be similarly efficacious with regard to their treatment of emesis caused by motion sickness. The literature is inconclusive regarding which drug would be more superior for PONV, or vertigo, and even though it has been suggested that prochlorperazine should be chosen over cyclizine when the nausea is severe, there does not seem to be any compelling evidence for this and many hospitals tend to choose cyclizine over prochlorperazine in their antiemetic protocols/guidelines. The most compelling evidence for choosing prochlorperazine over cyclizine in the autochthonic care setting would be the high abuse potential with cyclizine. However, in the secondary care setting this is of minimal concern. Therefore a more compelling reason for choosing prochlorperazine over cyclizine in this setting might largely hinge on the greater flexibility in formulations available for prochlorperazine. Whereas both drugs can be given orally as a tablet, when patients are vomiting this may be inappropriate. The buccal tablet or rectal suppository, which is available for prochlorperazine, and is less invasive than an injection formulation may be more acceptable to many patients in such cases.To conclude, the present essay has demonstrated that the nursing process for effectively dealing with emesis is repugn and complex. Here we have witnessed the plethora of facts which the nurse must take into enumerate prior to prescribing the antiemetic drugs cyclizine and prochlorperazine, and that even after attempting to optimise drug selection on the basis of such facts, success cannot be guaranteed. Ongoing monitoring of patient response/progress with the possibility of altering or augmenting the chosen drug therapy is necessary to improve outcomes, ensure patients receive optimal care, and that they bang maximal therapeutic success with minimal side effects.ReferencesMatchar DB, Young WB, Rosenberg JH, Michael P. Pietrzak, Stephen D. Silberstein, Richard B. Lipton and Nabih M. Ramadan. Evidence-based guidelines for migraine headache in the primary care setting Pharmacological guidance of acute attacks. Available at www.aan.com/public/practiceguidelines/03.pdf/. Accessed 28/10/12.CKS clinical Knowledge Summaries http//www.cks.nhs.uk/nausea_vomiting_in_pregnancy/management/prescribing_information/prochlorperazine/advice_about_prochlorperazineGoodman, L.S., an d A. Gilman. (eds.) The Pharmacological Basis of Therapeutics. 5th ed. New York Macmillan produce Co., Inc., 1975., p. 607).Benson A J, Medication for Motion S